Bioethical knowledge in students and health professionals: a systematic review

Introduction Bioethics training is essential for healthcare professionals as it enables them to address ethical dilemmas in their clinical practice. However, there is still a lack of rigorous teaching programs, and assessing bioethical knowledge poses challenges. Methodology: Systematic review using the PRISMA method. Results Analysis of 27 studies reveals a lack of ethical knowledge and skills among healthcare professionals and students. Specific training in bioethics is effective in developing bioethical competencies. Different approaches have been employed, including integrated training in academic curricula and intensive or ongoing programs. The results demonstrate improvements in knowledge, attitudes, and ethical values, although regularly updating these courses is recommended. Conclusion Specific training, institutional support, and considering regional and disciplinary differences are necessary to enhance ethics in the practice of healthcare professionals. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023437146, identifier CRD42023437146


Introduction
The training of healthcare professionals is usually focused on the study and acquisition of knowledge aimed at developing diagnostic and treatment competencies.Likewise, it should also be linked to the development of humanistic skills that allow these professionals to practice their profession with a balance between the technical and the human aspects (1)(2)(3)(4).This is highlighted by Striedinger (5) who argues that a framework of scientific and technical skills needs to be combined with a human dimension to address possible bioethical dilemmas that may arise in healthcare professions.
Training in bioethical aspects is a central and indispensable element that is progressively being included in the curricula of all health-related degrees.However, the training received is still inconsistent (5)(6)(7).This is mainly due to the need to approach the interactions between healthcare professionals and patients from a balanced technical and human perspective.While this may seem logical, evident, and indispensable nowadays, this reality is a recent consensus and has not always been a constant in health disciplines (8)(9)(10).All of this is supported by Reich (11), who describes the process of evolution and development undergone by Bioethics, indicating that, from its early stages, it has drawn on moral, medical, and theological philosophy (11)(12)(13), enabling it to achieve the unified and scientific vision presented in Potter (14) work "Bioethics: The science of survival." Through literature, the consolidation of Bioethics as an independent discipline is evidenced by the use of scientific methods inspired by those used in the humanities and social sciences (14)(15)(16)(17)(18).With the development of bioethics, an empirical approach based on "principlism" has been adopted, such as the Belmont Report (autonomy, beneficence, non-maleficence, justice) (19), and other more inductive logics (20).While the consolidation of this discipline is already a fact, there is still progress to be made regarding the transfer of bioethical knowledge to healthcare professionals (21)(22)(23)(24).
Given the tensions that exist between humanity and the practice of healthcare professionals regarding patients (25)(26)(27)(28), coupled with uncertainties arising from modifications in healthcare systems (29,30) and the impersonal advancement of new techniques, reflected in the substantial decrease, on the part of healthcare professionals, in the altruistic commitment to helping others (28)(29)(30), the importance of education in bioethics becomes evident in order to provide an optimal response in those moments when healthcare personnel may face ethical dilemmas (28,(31)(32)(33).
The humanization of healthcare services is directly related to the ethics, moral values, and professional deontology of healthcare agents toward the patient (34)(35)(36).Thus, bioethics seeks to combine humanism with the development of scientific knowledge, considering the patient not merely as a body or a medical process, but as a vulnerable human being facing illness (37)(38)(39).
The constant dissatisfactions of patients, who demand respect for their vulnerability in the face of illness, pose a challenge for healthcare institutions (34,(40)(41)(42).These institutions see bioethics as the link between health and humanization, reconciling clinical practice and the doctor-patient relational attitudes with ethical and moral reflection (43,44).Therefore, knowledge and education in bioethics are essential to acquire more humane competencies and improve care while safeguarding the dignity and quality of life of patients, especially in situations of vulnerability (34,(45)(46)(47).
Similarly, bioethics is applicable in the administrative field of healthcare centers, aiming to provide patient care with greater quality and humanism (41,(48)(49)(50).This includes the establishment of an Assisting Ethics Committee in each healthcare sector, based in the reference hospital of the sector (Article 28 of BOE-A-2011-8403, Law 10/2011, of March 24, on the rights and guarantees of the dignity of the person in the process of dying and death).
In recent years, there has been a growing interest among the scientific and professional community in improving the education received by professionals in this aspect (51,52).This is evidenced by the increasing, albeit limited, body of literature that points to the lack of rigorous teaching programs within university and professional contexts (6,(53)(54)(55)(56), and that encourages the creation of specialized curricula in this area (56)(57)(58)(59)(60)(61)(62), in order to progressively develop the capacity to face ethical conflicts through simulated and real environments (6,7,53).On the other hand, experts recommend problem-based learning (PBL), which allows students to acquire not only theoretical content and knowledge (knowing and understanding), but also reflective and evaluative abilities (knowing how to act) and the necessary competencies to resolve different situations related to the profession (54,(63)(64)(65)(66).
Espinoza Freire and Calva Nagua (67) and Carrera et al. ( 68) emphasize the need for this ethical education to start with the ethical training of academics since only through teacher education can the necessary knowledge be transmitted.This can be achieved through the implementation and design of new strategies that help mitigate the constant ethical dilemmas that arise in clinical practice and their consequences.
According to Culver (69), Bioethics education programs should not directly teach attitudes but rather focus on the identification of ethical conflicts that arise in clinical practice.Students should internalize the process for a rational response.
Couceiro-Vidal (54) highlights two main misconceptions regarding ethics education in healthcare.Firstly, the denial of freedom of conscience, and secondly, the presence of conflicts in the values due to the clinical relationship between healthcare professionals and patients and the paternalistic model that has been followed since ancient times.
Curriculum plans should take into account that moral development requires the development of schemas and different mental structures across six stages (obedience and punishment, individualism and exchange, interpersonal relationships, social order, social contract, and universal principles), which form three levels (pre-conventional, conventional, and post-conventional), as specified by León et al. (70), based on previous studies by Kohlberg (71).The latter two levels are where individuals seek the good for social and community wellbeing, understand that there are certain rules to be followed to live in a community, and use those norms to guide their actions in pursuit of the common good of their social group (71)(72)(73).At this level, individuals are capable of evolving toward full maturity of thought, establishing their own moral autonomy from which they can make absolute judgments of justice (70,(74)(75)(76).
In general, the academic and scientific community proposes a "common" model of aspects that would improve the method of teaching bioethics, subdividing it into "competencies to be achieved, " "knowledge, " and "skills" (54).It is suggested that in the preclinical period, basic bioethics should be taught, introducing students to the fundamental theoretical content.Then, in the clinical period, bioethics should be clinical, enabling students to learn skills to resolve specific conflicts that may arise in their clinical practice (66, [77][78][79].

Assessment of bioethical knowledge
The assessment of competencies, attitudes, and behaviors that align with the values being conveyed in academic content remains challenging due to the novelty of the discipline and the multitude of application contexts (80,81).In an effort to address this challenge, the academic and scientific community has sought to develop and implement existing examinations, such as the objective structured clinical examination (OSCE), as an evaluation methodology (82)(83)(84).The OSCE allows for the measurement of knowledge and the ability to ethically act in clinical situations (81,85), but it is unable to assess learning in other areas, such as behaviors based on acquired ethical values (81,86).In this line, Couceiro-Vidal (54,87), along with his proposal of problem-based learning (PBL), suggests a new evaluative method that allows for the objective assessment of bioethics learning in the clinical professional's practice, acknowledging the complexity of the entire process and following a similar curriculum design structure as other subjects taught.
Vera Carrasco (88) explains that, for a proper evaluation of bioethics learning, it should be conducted in three specific periods.Firstly, a diagnostic assessment is conducted at the beginning of the course to determine the subject's theoretical foundation.Secondly, during the course, there is a formative phase in which strengths and weaknesses in teaching should be identified.Lastly, a summative phase takes place at the end of the academic year, during which the instructor quantifies and grades the subject's acquired knowledge.This third phase is crucial as it allows for the identification of weaknesses and enables the instructor and the evaluated individual to engage in self-assessment.
Of the available scales for this purpose, the Hirsch (89), Hirsch (90) for the evaluation of attitudes toward professional ethics is worth highlighting.It is based on research conducted by Escámez Sánchez (91,92); Escámez Sánchez et al. (93), drawing from the ideas of Fishbein and Ajzens (94) "Theory of Reasoned Action" (1980), which conceives individuals as rational beings capable of judgment and evaluating situations (95,96).This scale consists of 55 items that are responded to using a 5-point Likert scale (1-completely disagree; 5-completely agree) and allows for the assessment of cognitive competencies, social competencies, ethical competencies, and affective-emotional competencies.Another relevant scale is the "Problem Identification Test" developed by Hebert et al. (97), which aims to evaluate ethical knowledge in students, defining it as "the ability of a person to recognize the existence of a moral problem" (98)(99)(100).This instrument uses 4 clinical cases to semi-quantitatively assess the recognition of three fundamental principles of bioethics (Autonomy, Beneficence, and Justice).
However, most studies measuring theoretical and applied bioethical knowledge rely on ad-hoc scales with questions specific to each author (90,(101)(102)(103)(104).In general, the design of questionnaires aimed at evaluating bioethical knowledge arises from professional experience and the needs faced by each teacher and/or area in bioethics (90,105,106).Hence, the importance of the teacher's attitude in creating evaluative methods focused on resolving ethical dilemmas encountered in their professional practice.
Therefore, this research aims to demonstrate the level of knowledge in bioethical aspects among students and healthcare faculty, as well as promote critical reflection on bioethical education for improved practice.

Study design
The methodological process was based on the recommendations presented by the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) statement (107)(108)(109)(110).All review phases were conducted in duplicate.
The protocol for this study was registered in PROSPERO (International Prospective Register of Systematic Reviews) under the ID: CRD42023437146.

Research strategy
The literature review was conducted between October and December 2022.To conduct the systematic review, a SPIDER framework (111)

Inclusion and exclusion criteria
To be included, studies had to meet the following criteria: (1) be published after 2019; (2) be written in English or Spanish; (3) provide previously unpublished original results; (4) aim to evaluate bioethical knowledge in the healthcare population or in training.Therefore, this work excluded literature reviews, systematic reviews, meta-analyses, books, general journals, editorials, comments on works, and articles that did not propose any intervention program and/or proposed it but not for the evaluation of bioethical knowledge in the healthcare population.

Selection process
After completing the search in all sources, a total of two reviewers screened the abstracts of the obtained results, using the Rayyan support tool for the initial exclusion criteria.In cases where there were doubts, an independent professional expert in bioethics was consulted.The data collected from the accepted articles were grouped into a database for synthesis and further discussion in this document.The following data were extracted from the accepted articles: (1) primary authorship, (2) year of publication, (3) methodology used, categorized as qualitative or quantitative methods, (4) sample used, including age and origin of the sample if available, (5) type of evaluation or intervention, indicating the type of resource used, name, items, and questionnaire administration time if applicable, (6) overall assessment of bias risk, and (7) main study results.
Regarding the reduction of bias risk, this review proposes different strategies, including (1) addressing biases from the accepted studies in the review, (2) managing biases in the synthesis of the collected information, (3) addressing biases from articles that should have been included in the review but were not, and (4) addressing biases caused by conflicts of interest and/or authorship funding.To reduce the bias risk arising from the analysis, synthesis, and reflections generated by the authors of this document, maximum transparency has been provided in the selection method, coding, bias analysis, and information synthesis, allowing future replication by other professionals and promoting inter-rater validity.In order to reduce the bias risk associated with not admitting articles that could have been accepted for various reasons (e.g., not being published in an indexed journal, language barriers, gray literature), a comprehensive search strategy has been designed, including specialized journals.

Results
Figure 1 shows the flowchart of the systematic review process.The literature search in databases yielded a total of 11,274 articles, out of which 6,460 were excluded for being published before 2019 or not being written in English or Spanish.Among the 4,814 identified articles, a total of 1,926 articles were discarded as duplicates.A total of 2,819 articles were rejected based on the title and abstract information; none of them were inaccessible, and the inter-rater consensus process was blinded.Therefore, a total of 69 articles were read in-depth and assessed for eligibility.Out of these, 42 articles were excluded from this study as their objective was not the evaluation of bioethical knowledge in the healthcare population.Finally, 27 articles were included in the present review.
To quantify knowledge in bioethics and related outcomes, adhoc questionnaires were used in 60% of cases (1,2,3,5,6,10,11,15,16,17,18,21,23,25,26,27).Among studies that employed standardized (113) scales, the Nursing Professional Values Scale-Revised (NPVS-R) was used in three studies, specifically designed to measure altruism, autonomy, knowledge, ethics, integrity, and justice in nursing professionals (12,13,14).The Kirkpatrick protocol was used in conjunction with the Semantic Differential Scale (22) or the TEKNeo (27) in two studies.One study combined the Objective Structural Clinical Examination (OSCE) with Self Reflection and Insight (SRIS) (24).Another study used the Social Justice Advocacy Scale and Moral Sensitivity Questionnaire together (9).The Nursing Dilemma Test and Moral Development Scale for Professionals were used together in another study (7).Similarly, the Defining Issue Test and Problem Identification Test by Hebert were used in conjunction in one study (20).Additionally, the Dental Ethical Sensitivity Scale (19), The Moral Competence Scale for Home Care Nurses (MCSHCN) (8), and semi-structured interviews (3, 10) were found.
The objectives outlined in the studies were diverse.Nearly half of the reviewed articles (2,4,9,15,20,21,22,23,24,25,27) aimed to evaluate the effectiveness of bioethics education through curriculum implementation or specific training.On the other hand, six studies focused on assessing knowledge in ethics, as well as individuals' attitudes and competencies related to it (1, 5, 8, 17, 18, and 26).The study by Maluwa et al. (114) went further by attempting to identify determinants of adequate ethical competence.Four studies sought to analyze the reflection process associated with decision-making in ethical dilemmas present in healthcare practice (6,7,10,11).Furthermore, three studies aimed to explore differences in professional values among different training programs or geographical locations (112,115,116).

Bioethical knowledge
The analysis of the studies demonstrates that, in general, there is insufficient knowledge in the field of medical ethics and/or skills for resolving ethical conflicts among healthcare professionals and students.There is also a perceived lack of support from universities and workplaces, and there is consensus on the need to incorporate mandatory training in professional ethics (6,7,8,10).However, it is observed that work experience and level of education completed are associated with an improvement in knowledge and ethical values (13,14,17,20).
Despite this, in terms of ethical competence or knowledge, there do not seem to be significant differences based on gender or professional role (4,7,8,11,13,19).However, it is important to note that, regarding the selected outcome variable, these results are not consistent across all studies.Some studies show that women have higher postconventional moral reasoning (17,20), which is associated with a higher level of ethical competence in professional practice.There are also cases where dental professionals have lower ethical knowledge compared to their counterparts in nursing, medicine, or physiotherapy (11,26).
On the other hand, significant differences exist in terms of bioethical knowledge, attitudes, values, or professionalism based on the geographical region of reference.Developed regions, such as the United States, tend to show higher scores than less developed regions like Malawi or Ethiopia (6,12,13).The same applies when comparing education in public and private universities, where students from private universities tend to achieve higher scores in ethical knowledge (16).

Characteristics and effectiveness of training
Out of the 27 articles analyzed, 16 included bioethics training as an independent variable, and the majority of them demonstrated that specific bioethics training is effective in developing bioethical knowledge, attitudes, values, or competencies for professional practice.These bioethics trainings showed significant heterogeneity in terms of their format and duration.
In the case of undergraduate student training, 4 studies proposed integrated training programs within academic curricula (2,9,20,24), while 6 studies presented complementary programs external to the curriculum (1,4,9,11,15,21,22).In the case of integrated training within the curriculum, the training combined theory and practice, utilizing clinical cases, vignettes, discussion forums, simulation scenarios, among others.For trainings outside the academic curriculum, the proposed programs had a shorter duration (between 3 and 16 sessions) and were characterized by experiential learning through didactic tools such as problem-based learning (PBL and CBL), case dramatization, lectures delivered by renowned professionals, problem-solving in complex simulation scenarios, or the use of mobile applications.
Training programs for practicing professionals exhibit a variety of structures, but all of them are equally effective.It is possible to distinguish between intensive proposals and ongoing proposals over time.On the other hand, the program developed by Geis et al. (118) consists of 13 ethics modules targeted at neonatology fellows.This program has been effectively tested in three academic institutions using a flipped classroom approach.The modules cover a wide range of topics in bioethics, such as principles of bioethics, maternal-fetal decision-making, professionalism and communication, prenatal counseling, withholding or withdrawing life-sustaining treatment, cultural sensitivity, genetic screening, palliative care, social justice and resource allocation, law and ethics, moral dilemma and physician awareness, disclosure of medical errors, and research ethics.
Intensive programs have also proven to be effective in developing ethical competencies.Sinha et al. (119) proposes a theoretical seminar that addresses knowledge, beliefs, and attitudes related to principles and clinical practice.This approach successfully improves the knowledge of participating medical professionals who underwent the program.
On the other hand, Wall (120) suggests a 74-min didactic seminar targeted at oncology nurses.Techniques such as storytelling, role-playing, and simulation are used in this seminar.The presented stories illustrate the role of oncology nurses in protecting and advocating for vulnerable patients, respecting and adapting to cultural differences, and increasing self-awareness of personal values that may influence decisions.According to the findings, there is a significant short-and medium-term improvement in the ethical competencies of nurses.However, it is suggested that these trainings need to be regularly renewed and updated as a stagnation in long-term improvement has been observed.
Furthermore, Momennasab et al. (121) propose bioethics training for nurses through independent reading of cases that present various ethical conflicts in relation to the professional code of ethics, followed by group reflection.This approach shows improvement in attitude and ability to resolve ethical conflicts, although no significant improvement is observed in ethical knowledge.

Discussion
This review summarizes the findings of studies that address the analysis of bioethical knowledge in healthcare students and professionals, as well as the perception of knowledge and ethical competencies in healthcare professionals and students.Twenty-seven studies were systematically reviewed, all of which demonstrate the reality of existing bioethical knowledge and education in healthcare settings.To distinguish between the reviewed studies and other evidence, the reviewed studies will be cited using the assigned numbers in Table 1.

Findings on bioethical knowledge and education in the field of healthcare
Overall, the evidence from the reviewed studies suggests that education in ethics and bioethics in the healthcare field is a topic of increasing interest, both in academic and professional contexts.This is because healthcare professionals constantly face complex ethical situations in their daily practice.
Drawing conclusions regarding the competence of healthcare students and professionals in terms of knowledge and skills to address bioethical dilemmas is challenging, as the analysis of the studies presents conflicting results.On one hand, there are studies that reveal a lack of sufficient knowledge in the field of medical ethics and skills for ethical conflict resolution among healthcare professionals and students (6, 7, 10), while others conclude adequate levels of knowledge in this population (8,16).These results are consistent with what has been pointed out by Bellver Capella (122), Suárez Alba and Artiles Chaviano (123), and they confirm the ongoing difficulty in drawing solid conclusions due to the disparity of theoretical conceptualizations and procedures employed in different studies, as well as the limited representation of healthcare professions other than medicine or nursing.
Despite the existing deficiencies, it is observed that work experience and the level of completed education appear to be associated with an improvement in knowledge and ethical values (13,14,17).This indicates that time and exposure to ethical situations in professional practice can contribute to the development of ethical competencies (124)(125)(126).Additionally, there is evidence of a perceived lack of support from universities and workplaces in the development of ethical competencies.This deficiency is reflected in the consensus on the need to incorporate mandatory training in professional ethics (28,(31)(32)(33).
When analyzing differences based on gender and professional role, heterogeneous results have been found.In some studies, no significant differences have been identified in terms of ethical competence or knowledge (4,7,8,11,13), following the findings of authors such as Coffin-Cabrera et al. (127) or Sanz Ponce and Hirsch Adler (128).However, in other cases, it has been observed that women exhibit higher postconventional moral reasoning, which has been associated with a higher level of ethical competence in professional practice (17,20), as stated by Barba (129) and Barba and Romo (130).On the other hand, it has been observed that dental professionals show a lower level of ethical knowledge compared to their nursing, medical, or physiotherapy counterparts (11,26).These differences may be influenced by specific contextual and educational factors of each profession, as similarly asserted by García-Vilanova and Pérez (6), Nicoletti et al. (7), and Striedinger (5).
Another relevant aspect identified in the conducted review is the influence of geographical region and university type on ethical knowledge and competencies.Studies indicate that more developed regions, such as the United States, demonstrate higher scores in professional ethics compared to less developed regions like Tanzania or Ethiopia (6,13).Additionally, it has been found that students studying at private universities achieve higher scores in ethical knowledge compared to those studying at public universities (16).These differences may be related to the availability of resources and the educational approach adopted in each context (130-133).An ad hoc pre-and post-intervention survey was conducted.
Five-hour sessions were held over the course of 14 months.Within the core curriculum, there was one introductory didactic session and three sessions focused on specific topics and case-based discussions.An additional second introductory session was conducted between sessions 2 and 3 to ensure that new medical pathology graduates from Emory were fully oriented to the curriculum objectives.The introductory sessions consisted of a 45-min to 1-h didactic presentation, which described the need for ethical education for pathology learners, basic terms and concepts, and the structure and objectives of the curriculum.
Most of the sample found the curriculum useful and learned something new after completing it.They also believed that a basic understanding and application of ethics and professionalism are essential to their current and future pathology practice.

Spain
Analyze nursing students' perceptions of professional values throughout the 4 years of education.

N = 315 nursing students
Cross-sectional descriptive study.
The EVPS (Nursing Professional Value Scale Revised) is a self-administered instrument consisting of 26 items, divided into three dimensions: ethics, professional competence, and professional mastery.Each response is provided using a 5-point Likert scale of importance: ( 1) not important at all, (2) somewhat important, (3) important, (4) very important, and ( 5) extremely important.The respondents selected the degree of importance they assigned to each nursing practice value statement.
The students' perceptions of professional values were found to be significantly correlated with their academic year.Overall, the students scored higher in the ethics dimension.This suggests that as students progress through their nursing education, they develop a stronger understanding and importance placed on ethical considerations in their professional practice.Methodological limitations in research on bioethical knowledge in the health field In the context of ethics and bioethics training strategies, there is variability in terms of approaches and durations.The examined studies used both ad-hoc training and standardized scales to assess knowledge and ethical outcomes.In most cases, ad-hoc questionnaires were implemented to measure ethical knowledge (1,2,3,5,6,10,11,15,16,17,18,21,23,25,26,27).Additionally, specific scales (113) such as the Nursing Professional Values Scale-Revised (NPVS-R) were employed to evaluate ethical values in nursing professionals (12,13,14), which consists of six main dimensions: altruism, autonomy, knowledge, ethics, integrity, and justice.
The objectives set in the studies were also diverse.One of the most common objectives was to evaluate the effectiveness of bioethics training through the implementation of curricula or specific training programs (2,4,9,15,20,21,22,23,24,25,27).Additionally, the aim was to assess the knowledge, attitudes, and ethical competencies of individuals (1,5,8,17,18,26) and analyze the reflective process associated with ethical decision-making in healthcare practice (6,7,10,11).
Overall, the results indicate that specific bioethics training is effective in developing ethical knowledge, attitudes, values, and competencies in both students and practicing professionals.Both integrated curriculum-based training and external supplementary training have proven to be effective.These trainings combine theory with practice, utilizing didactic tools such as clinical cases, vignettes, discussion forums, simulation scenarios, and mobile applications.
Furthermore, training targeted at practicing professionals has also demonstrated their efficacy.Intensive and long-term programs have been proposed.Some intensive programs focus on theoretical seminars, while others adopt more participatory approaches such as storytelling techniques, role-playing, and simulation.These programs have successfully improved the ethical competencies of physicians and nurses, as well as promoted reflection on personal values that may influence ethical decisions.
However, it is important to highlight the need for ongoing updating and renewal of these training.It has been observed that, in the long term, stagnation in results may occur, indicating that ethical training should be a continuous and dynamic process to ensure its effectiveness over time (23).This idea aligns with the views of authors such as Alarcón and Chapa (134), Tarzian and Asbh Core Competencies Update Task Force (135), and White (136).
In summary, the reviewed studies provide evidence for the importance of ethics and bioethics training for professionals and students in the healthcare field.Despite existing limitations, specific bioethics training has proven effective in developing ethical knowledge, attitudes, values, and competencies.Both integrated curriculum-based training and external supplementary training have yielded positive results in enhancing ethical competencies.Intensive and ongoing programs have also shown favorable outcomes.However, continuous updating of these training is necessary to maintain their long-term impact.

Conclusion
To conclude, the analysis of the 27 reviewed scientific articles in the field of medical ethics and bioethics reveals a lack of knowledge and skills to address ethical conflicts among healthcare professionals and students.Specific training in bioethics has been identified as an effective strategy to improve ethical knowledge, attitudes, values, and competencies in professional practice.
However, there is a lack of support from academic institutions and workplaces in implementing mandatory training programs in professional ethics.The importance of work experience and educational level as factors associated with improvement in ethical knowledge and values is highlighted.
Furthermore, significant differences were found in terms of ethical knowledge based on geographical region and healthcare discipline.Developed regions and certain disciplines showed better results in terms of ethical knowledge.These findings emphasize the need to consider regional and disciplinary specificities when designing ethical training programs.
A comprehensive approach is required to promote ethical training in the healthcare field.This involves incorporating medical ethics into academic curricula, providing continuous and effective training programs for practicing professionals, and addressing the specific needs of each regional and disciplinary context.Enhancing ethical and quality practice in the healthcare field is crucial to ensure the wellbeing of patients and the professional development of healthcare providers. 10.3389/fmed.2024.1252386
Among the ongoing proposals, an example is the training program called "Teach for Ethics in Palliative Care" (T4EPC) proposed by De Panfilis et al. (117).This program consists of 28 h of training distributed over several weeks.During this time, professionals receive theoretical training (8 h), practical training (10 h), and individual mentoring (10 h).This training approach has proven to be effective in improving the professional practice of physicians, nurses, and psychologists who have completed the program.

TABLE 1
Summary of the reviewed studies.